Santa Clara County’s Complex Care Services Program was launched in 2022 to provide additional individualized support for patients who need it most. Housed within this program is the Integrated Care Team (ICT) that specializes in working with patients with severe behavioral and executive functioning disorders. It is one of the only teams across the country to specifically serve this population using this innovative model.
Peter was one of the first patients that the Integrated Care Team supported, and it changed his life.
Unemployed and unhoused, Peter was struggling to manage his bipolar disorder and anxiety during this difficult time. Peter was eventually connected to the Valley Homeless Healthcare Program - but he had difficulty navigating the resources available and being consistent with his appointments.
Before he was connected to ICT, Peter was averaging 4-5 visits to the Emergency Room per month. “A lot of patients with cognitive and behavioral issues are utilizing the ER because they don’t know how to use the system and it strains the system while not being the most effective way for them to receive care,” ICT Care Coordinator Vince Beardsley shared.
For these patients, ICT is a lifeline, providing them individualized case management and support to help address their care needs and navigate the healthcare system.
Vince reached out to Peter in August 2022 and was able to provide Peter with clothing, food, and other essentials thanks to the support of Valley Health Foundation (and you!).
Vince helped Peter get reconnected to the health system and the services he needed, including establishing care with a primary care doctor and Behavioral Health. Vince also helped him follow through with his appointments through regular check-ins and helping to drive him to his appointments. The team also helped him connect to community resources, including, most importantly, stable housing.
Thanks to working with the ICT, Peter is able to better manage his health and has only had 8 ER visits since last August, when he first was connected to Vince. Today, he lives in an independent living facility and is working towards finding a job. Peter and Vince continue to check in to support Peter in his care and focus on his health.
“They really helped me better my life,” Peter said. “I have a stronger foundation and it allows me to now help others when I can. I can now tell others that it is possible.”